• Atkinson Family Practice

    17 Research Dr., Amherst, MA  01002

    413-549-8400

    Dr. Nora Schwartz Martin

  • TMS Welcome Packet

    We feel we have something very special here at Atkinson Family Practice and we look forward to caring for you. Let us tell you more about ourselves and our philosophy regarding patient care.
  • We are very excited to offer TMS at Atkinson Family Practice.  We are an integrative practice that fully believes in healing minds and bodies.  We believe TMS is a great addition to the services we offer and are so glad that you chose us for this journey.  Below are some key policies that can help keep your appointments running as smoothly as possible.

    Appointments:  We ask that you give 24 hours' notice if you are unable to  make any appointments.  We try to schedule these as far out as possible and have extended hours most days to t ry and accommodate most schedules.  We understand that sometimes things come up that are unavoidable and just ask for as much noticed as possible.  If you do cancel or no show an appointment there is a $50 fee.  We may waive the fee if only one appointment is missed.  In addition, if you are fifteen minutes late or more to an appointment, we cannot guarantee that we can see you that day. We frequently book back-to-back appointments so it is very important that you come to all of your appointments on time.  If you are going to be late please call to inform us.  We may ask you to reschedule or cancel your appointment.

    Insurance: There are many, many insurances each with many different programs--we cannot know what your insurance actually covers.  You are responsible to know what your policy states.  We will  work with you to find out your financial responsibility and obtain a prior authorization; however, these are not a guarantee of payment.  We do not set your co-pay or deductible--your policy does.  After your insurance has paid we will expect you to pay the balance in a reasonable amount of time.  We have dedicated billers who are available if you have any questions.  We will generally work out a reasonable payment schedule during your mapping visit.

    Payments: We count on your payments to keep our office operating.  You are responsible for paying for your own medical care.  We sign contracts with your insurers agreeing to collect co-pay, so we are not able to waive them.  We would appreciate your not asking us to do so.  Please note: If we have to send a statement after treatment there may be an additional fee of $10. If a check is returned for non-payment, there will be a $30 bounced-check fee applied to your account and check writing will be prohibited with our office.

    PHONE:  Our office phone is 413-549-8400.  Our phones are on weekdays 7:30am to 7:00pm Monday through Thursday and 7:30am to 5pm on Friday.  We are off for lunch from 12:30-1:30pm every day.  You may leave a message with the front desk for our TMS coordinator or Dr. Nora and we will respond within 24 hours.

    EMAIL: You can email Kimberly, our TMS Coordinator at krose@doctorkate.net.  She will forward any correspondence to Dr. Nora directly.

  • TMS Patient Form

    Patient Information
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  • Referral Information:

  • Please check off any medical trials that you have tried

  • Quick History

  • In case of an Emergency, who can we notify?

  • List of Medications

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  • HIPAA

    Contact Information/Privacy Consent
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  • Statement of Understanding

    Assumption of Financial Responsibility for Medical Services
  • I am enrolled in the following insurance plan(s):

  • I acknowledge that I have voluntarily sought the services of Atkinson Family Practice, a participating provider.  I accept full responsibility for paying for services provided by Katherine Atkinson, MD, PC.  I understand that my insurer will not pay the provider nor reimburse me for the cost of services rendered here, or for any subsequent or ancillary services which the provider may order on my behalf, if this insurance is not truly in effect or if the provider is not considered my primary care physician.  I further acknowledge that it is my responsbility and not the provider's to know what services are covered by my insurer.  I accept full responsibility for paying for services provided if they are not covered by my insurance. If the above information changes at any point, it is my responsibility to notify Atkinson Family Practice.

     

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  • Assignment and Release

  • I certify that I and/or my dependents assign our insurance benefits directly to Katherine J. Atkinson, MD, PC.  I understand that I am financially responsible for all charges whether or not they are paid by the insurance company.  I authorize the use of my signature on all insurance submissions.  I certify that Katherine J. Atkinson, MD, PC and its employees have the right to disclose my (or my dependents') health care information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits and payments for related services.  This consent will remain active unless I cancel it in writing.

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  • Authorization for Release of Medical Information

    All sections below must be completed for processing
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  • OBTAIN MEDICAL RECORDS

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  • DISCLOSE MEDICAL RECORDS

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  • Release of sensitive, protected information related to testing, diagnosis and/or treatment for HIV/AIDS, sexually transmitted diseases, drug/alcohol use/treatment and/or mental health/psychiatry is authorized only through express consent.

    INDICATE THE AREAS YOU AUTHORIZE BY INITIALING EACH ONE BELOW. Authorization is not valid without initials.

  • This authorization expires on the below date, or if unspecified, one year from your date of signature:

  • I understand that I may revoke this authorization at any time by making a written request to Atkinson Family Practice.  I understand that actions taken in reliance on this authorization prior to revocations may not be reversible.  I understand that Atkinson Family Practice may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization.  State law prohibits redisclosure without written authorization.

    I acknowledge that I have signed this authorization voluntarily:

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  • Quality of Life Scale (QOL)

    Please read each item and fill in the number that best describes how satisfied you are at this time. Please answer each item even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the relationship.
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  • Beck's Depression Inventory

    This depression inventory can be self-scored. The scored scale is at the end of the questionnaire.
  • INTERPRETING THE BECK DEPRESSION INVENTORY

    Now that you have completed the questionnaire, add up the score for each of the twenty-one questions by counting the number to the right of each question you marked.  The highest possible total for the test would be 63.  This would mean you circled number  three on all twenty-one questions.  Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero.  You can evaluate your depression according to the table below:

    TOTAL SCORE                                          Levels of Depression

    1-10                                                     These ups and downs are normal

    11-16                                                    Mild mood disturbance

    17-20                                                    Borderline clinical depression

    21-30                                                    Moderate depression

    31-40                                                    Severe depression

    over 40                                                  Extreme depression

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